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Saturday, April 18, 2009

Medical Ethics and Social Justice

In a recent JAMA Commentary[1], Darrell Kirch, MD, President of the Association of American Medical Colleges (AAMC) and his colleague David J. Vernon, speak about the “Ethical foundation of American medicine”. They discuss the 4 traditional components of medical ethics: beneficence (do the right thing, or “provide good care”), nonmaleficence (don’t do the wrong thing, “do no harm”), respect for autonomy, and justice. They note that the first two have been the most emphasized in medical ethics and “are foremost in the minds of physicians”. In general, these two are the most obvious ones individual patients, as well as society, would desire to have done, although they can sometimes be very complex and lead to difficult decisions when the line between “do the right thing” and “don’t do the wrong thing” is not perfectly clear.

The authors briefly address respect for autonomy, noting that this includes physician, as well as patient, autonomy, discussing the fact that physicians have “delegated authority” from society, which confers them privileges in return for their using “…their best informed judgment when caring for individuals who need assistance…”. They express significant concern about the degree of physician autonomy in a market-driven system, where “fiscal independence” and the “right to enhance physician revenues” seem to “…have become as important as autonomous decision making in practice…” The result of this, they fear, is that “…attention to social justice [the fourth tenet of medical ethics] may be decreased.” It is this tenet, social justice, to which they dedicate the remainder of their discussion.

They cite Rawls’ theory of justice[2][3], “often referred to as social justice” as a dominant theory of justice. The two components of this theory, which are also core to the content of this blog, are:

· “People should have maximal liberty compatible with the same degree of liberty for everyone” and· “Deliberate inequalities are unjust unless they work to the advantage of the least well off.”

Wow. What concepts! The first states that your liberty does not allow you to hurt me, and the second that policies of justice must work to the benefit of the least well off. This is, of course, completely opposite to the trends of the last many years in the US, where the intent of policy has been to be to the advantage of the most well off. This concept is applicable far beyond medicine, prominently including legislative / governmental policy, based on the idea that socially (that is, in addition to issues such as providing for the common defense) the role of government should be to help those most, rather than least in need. The presumption is that those who are “most well off”, are, well, most well off, and least in need of help from the rest of society. Similarly, in regard to health care, it is those who have the least resources – to purchase medication, to take time off from work to see a doctor, to have the most dangerous jobs, to have no job, to have inadequate food or housing – who have the greatest need. Yet, in both cases, governmental and medical, we have not followed this precept; governmentally, it is those with the loudest voices and the most money who have the ears, and service from, government (problem: poor people just don’t contribute enough to politicians!); medically, the greatest resources go to those who have the best insurance, often not those with the greatest need.

Kirch and Vernon look at the difficulties that inhibit physician pursuit of the goals of social justice. They note 3 “interrelated” factors:

“Fundamental human behavior. Physicians, like most individuals, seek and compete for opportunities within their current circumstance to create the best life possible for them and their families.” This means that, while they will (hopefully) offer the best care to their individual patients, they may look first to making more money than expanding to Medicare, Medicaid, or self-pay patients. They observe that the flaw here is that “…for each of the physicians who decide they can no longer care for these patients, the responsibility falls to another clinician.” Perhaps, but that clinician may be in the ER when the patient presents with far-advanced disease because no one in the community will see him/her. (Plus I am always leery of phrases like “fundamental human behavior” and “it’s human nature”; like “I’m sure I speak for all of us when I say…”, there are almost always exceptions!)

Medical student debt. This means not only that students have to make a lot of money to pay it back, but that the socioeconomic background of those going to medical school may become even more imbalanced than it already is (they say “…more than 75% of medical students came from families the top 2 quintiles of family income…”). Facing this debt, maybe those from non-wealthy families will seek other careers.

The US culture of “individualism”. “Specifically regarding health care, many other western nations have some form of universal coverage supported by their government and treat health care as a public good.” Right. And so could we. Especially as we not only spend far more money per capita on health care than any of them, but we actually spend more public money (Medicare, Medicaid, federal, state and local employees, military, VA, and the taxes lost because employer contributions to health insurance are tax deductible) per capita than any other country!

They worry that “…the emphasis on individual responsibility may be deepening,…” citing a study by Lee, et.al. that showed that “…the percentage of Americans who agree that the high the income, the more the individual should expect to pay in taxes to cover the cost of care for individuals who are less well off decreased from 66% in 1991 to 51% in 2003 and to 39% in 2006.”[4] However, this is one study, focusing on the highest cost drugs; study after study has shown that a majority of Americans see the need for a universal health care system and are willing to pay more taxes to achieve it.[5] A majority of physicians support national health insurance.[6] Although, I again note, the taxes for most people would be more than offset by not having to pay for health insurance. And the number of people who have no insurance, inadequate insurance (high deductible, low maximum limit, excluded conditions), sporadic insurance, or think they were insured but still find themselves financially ruined by disease treatment costs – and people who know, work with, and are related to them and thus feel their pain – grows every year.

The 4 principles of ethics are all important, but the emphasis on social justice, in this time and place, is critical. Kirch and Vernon conclude:

“Physicians have a responsibility to ask and answer these difficult questions that are properly viewed as not simply involving politics, but rather as speaking to fundamental medical ethics. The answers in turn may well require personal sacrifices (eg, accepting a lower level of income), professional group action (eg, advocating as much for health care system improvements as current advocacy for the preservation of specialty reimbursement levels), and a commitment to work within the political process (that goes beyond lobbying for maintenance of the status quo). These efforts and corresponding sacrifices are necessary first steps toward creating a society in which everyone has access to appropriate health care.”

Amen. I would add that it is also critical that in medicine, and in medical education, that these are not issues relegated only to special courses in “medical ethics” but are rather core values informing all of what we do.[1] Kirch DG, Vernon DJ, “The ethical foundation of American medicine: in search of social justice”, JAMA 8Apr2009; 301(14):1482-4.[2] Rawls J. A Theory of Justice. Cambridge, Massachusetts: Belknap Press of Harvard University Press, 1971. Revised edition 1999.[3] Gillon R. Justice and medical ethics. Fr Med J (Clin Res Ed). 1985;291(6489):201-202 (This is the reference the authors cite for their discussion of Rawls’ theory of justice)[4] Lee TH, Emanuel EJ, “Tier 4 drugs and the fraying of the social compact”, NEJM 2008;359(4):333-5.[5] CNN Poll, May 4-6, 2007, http://i.a.cnn.net/cnn/2007/images/05/09/rel6e.pdf, Question #30, accessed 4/15/09[6] Carroll AE, Ackerman RT, “Support for national health insurance among US physicians: 5 years later”, Ann Int Med 1Apr2008;148(7):565-7.